BRIEF COMMUNICATION
The Importance of Social Context in Understanding and Promoting Low-Income Immigrant Women’s Health Maria De Jesus, PhD Abstract: Understanding the social context and realities of Cape Verdean women in the U.S. as well as other immigrant and ethnic/racial groups is important to promote their overall health and well-being more effectively. The aim of this study was to gain a contextual understanding from the perspectives of health promoters who work with marginalized women. In-depth, semi-structured interviews were conducted with nine Cape Verdean women health promoters about their perspectives and experiences of health promotion practice with immigrant women in their community. Using a Glaserian grounded theory approach to analysis, six salient themes describing women’s social context emerged: community and domestic violence, loss and isolation, economic injustice, immigration-related issues and abuse, unequal gender-based power relations, and cultural taboos. These findings challenge health researchers and practitioners to understand health problems and health promotion not only at an individual level, but at multiple levels of influence including interpersonal, family, neighborhood, and structural levels. Key words: Cape Verdean health promoters, immigrant women, health promotion, social context.
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n recent years, public health research has increasingly focused on the importance of the social context in understanding and promoting the health and well-being of individuals and communities.1–2 As such, social-contextual theoretical models have been developed explicating the role of social contextual factors on health and health promotion programs across multiple levels of influence (e.g., individual, interpersonal, neighborhood).3–6 In particular, immigrant health research brings to light the importance of understanding the social context of immigrant populations for effective community health promotion practice.7–8 To date there have been no published public health journal articles examining the social context of low-income immigrant women from the Cape Verde. Studies with this population are important for several reasons. First, this immigrant population is growing in the U.S. It is estimated that the number of people with Cape Verdean ancestry in the U.S., including both migrants and their descendants, is higher than MARIA DE JESUS is affiliated with the Harvard School of Public Health, Department of Society, Human Development, and Health and Center for Community-Based Research, Dana Farber Cancer Institute, in Boston, Massachusetts. Please direct correspondence to her at 44 Binney Street—LW703, Boston, MA 02115; (617) 582-7468;
[email protected]. Journal of Health Care for the Poor and Underserved 20 (2009): 90–97.
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in any other country.9 According to the 2000 U.S. Census, there are approximately 77,000 Cape Verdeans in the country. The majority of this population has settled in major cities in New England. Second, increasing the body of knowledge on this specific immigrant group and the specific contextual and sociocultural stressors to which Cape Verdean women in particular are exposed can contribute to the provision of culturally competent health care. Third, research focused on Cape Verdean immigrant women can also facilitate and support their transition and integration into different sectors of U.S. society, including the health care system.10 Thus, this study aims to fill a gap in the literature by examining the social context of Cape Verdean immigrant women through the epistemological standpoint and practice of community-based health promoters who work with these women on health promotion issues and who served as key informants in the study. Health promoters can be defined as “members of communities who work either for pay or as volunteers in association with the local health care system in both urban and rural environments and usually share ethnicity, language, socioeconomic status, and life experiences with the community members they serve.”11, p. iii They have a long history of providing public health services in many different cultures and countries, especially among groups that have been denied adequate health care, such as minority and socio-economically disadvantaged populations in resource-poor neighborhoods.12 Previous research with health promoters who are community members report that health promoters are uniquely equipped to reach these underserved communities because they are able to understand community problems in context, and to develop innovative health interventions that respond to women’s realities.13–17
Methods This community-based qualitative research was grounded in an emic or idiographic approach to research which “concerns itself with the specific and unique richness of a phenomenon, so that we understand the particular (the individual, the subjective) rather than the general.”18, p. 26 An in-depth understanding of the Cape Verdean community in an urban Massachusetts setting, which evolved through 18 months of fieldwork on an earlier project with this community,19 facilitated the researcher’s entry for the community-based research described here. In order to understand health promotion—or its absence—within this community better, data were collected through ethnographic observations, community mapping exercises, open-ended semi-structured interviews and a focus group20 with local health promoters from September 2004 to January 2006. The data gathered through multiple and diverse sources increases internal validity, in part, by a process of triangulation that provides a more complete picture of health promotion with Cape Verdean immigrant women. Data from the interviews will be discussed in this paper. Nine key informants were identified using a purposeful sampling technique; that is, Cape Verdean health promoters initially identified through previous research as being knowledgeable about health promotion with Cape Verdean immigrant women due to their positions in local health organizations provided recommendations for additional informants.19 They were all members of the community they serve and stated that the
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primary reason they decided to become health promoters was “to give back to my community.” All the participants were 25 to 38 years old. Five were born in Cape Verde and the other four were born in the U.S. Those who immigrated had been in the U.S. for over 20 years. They all spoke English and Kriolu, the indigenous language of Cape Verde. In addition, six health promoters also spoke at least one other language (e.g., Portuguese, French). On average, they had been working as health promoters for 6 years (Table 1). Their training included understanding medical and social services, coordinating access to services, outreach, home visiting, client advocacy, cultural awareness, and patient navigation. Approval from the Boston College Institutional Review Board was received prior to interviewing the participants. A pseudonym was selected for each participant. The purposes of the study were clarified and informed consent was obtained from all participants prior to the interviews. In the first set of individual interviews, the researcher described the goals of the research, collected demographic information, and asked participants open-ended semi-structured questions that invited rich stories about their work with Cape Verdean immigrant women and the contextual barriers encountered by the women. The second set of individual interviews was designed to explore points of particular interest in more depth and to expand on illustrative examples drawn from their work. Saturation, that is, when more interviews were not adding any new themes or concepts to what was already known, was achieved with these nine health promoters.21 Each interview lasted between 1.5 to two hours. Lastly, a focus group with participants was conducted for member-checking (i.e., presenting the findings to the participants who then commented on the representation of the findings).22 These discussions served to deepen the analysis. Memo-writing (i.e., the write-up of theoretical ideas about substantive concepts and their theoretically coded relationships as they
Table 1. CAPE VERDEAN WOMEN HEALTH PROMOTERS AND DEMOGRAPHIC INFORMATION Participant (pseudonym) Gabriela Alice Rosie Ana Lucia Natalia Sandra Marlene Mabel
Age
Years as Health Promoter
29 36 33 38 36 34 25 28 33
8 4 5 16 6 6 2 4 3
Languages Spoken Kriolu, Portuguese, English, Spanish Kriolu, Portuguese, English Kriolu, Portuguese, English, Spanish Kriolu, Portuguese, English, Spanish Kriolu, English Kriolu, Portuguese, English Kriolu, English Kriolu, English Kriolu, Portuguese, English
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emerge during data collection and analysis) throughout the research process shaped subsequent data collection, pointing to areas for further exploration.22 Data analysis. The data were analyzed using a Glaserian grounded theory approach. Grounded theory is an inductive and systematic approach to data analysis, meaning that analysis proceeds from making specific observations based on stories gathered from the participant to developing more abstract concepts.22 Given the lack of previous research with this population, this approach provided a resource for identifying concepts and developing an iterative process through which to theorize about the social context of Cape Verdean immigrant women.
Results There were six salient themes that emerged from the interviews with the health promoters: community and domestic violence, loss and isolation, economic injustice, immigration-related issues and abuse, unequal gender-based power relations, and cultural taboos. Community and domestic violence. Health promoters’ definitions of health were informed by the contextual lens through which they understood health promotion with immigrant women. As Ana (a 38-year-old health promoter from Cape Verde with 16 years of experience) aptly described it: As health promoters, we define health differently than how a physical or mental health provider would define health. Health is not only related to women at an individual level, but it is also concerned with what is happening in the community and with what makes a community healthy. For example, being healthy right now for Cape Verdean women means to not have guns on the streets. It is not to have domestic violence occur. It is not to see women being abused. It is not to see a lot of youngsters in jail. It is not to see women being exploited or young girls, even right now around this community, being exploited by gang members. This is what “health” means for us. Many different types of abuse contribute to depression and physical ailments for these women.
Similarly, Lucia (a 36-year-old health promoter who was born in the U.S. and has six years of experience) stated, “I work with individual and community dynamics. And if you want to call peace in the home and in the community a health process, then let us call it that because if you do not have peace in your home and in your community, then nothing is balanced and the stresses damage a woman mentally, physically, and emotionally.” Loss and isolation. Lucia recounted how the health problems of many women in the community were related to a larger context of loss and violence: Last year, a co-worker and I ran a support group for Cape Verdean immigrant women who had lost their child either through deportation, incarceration or murder. There were so many women in the community affected by these issues. And the women were just hiding out in their houses, not having anyone to talk to, not having anyone who could understand their pain, not knowing what to do, and just literally isolating
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Social context and immigrant women’s health themselves from everyone. We formed a group of about nine women and just to hear their stories was powerful. Most of them suffered from health problems such as high blood pressure, headaches, and depression.
Economic injustice. Health promoters also described how unjust economic structural realities had a detrimental effect on the health of women and their families. As Gabriela (a 29-year-old health promoter from Cape Verde with eight years of experience) explained, “Understanding that rent in this community is now $1,200.00 and women here are working at minimum wage, how can you make it? How do you make it all come together? It puts a strain on women and their families which again negatively affects women’s health.” Health-related issues pale vis-à-vis more urgent, bread and butter issues such as work. As Sandra (a 25-year-old health promoter who was born in the U.S. and is in her second year of practice) recounted: We did everything possible to get community women to come in for meetings to talk about their health. . . . The day Zoots [dry cleaning company] came in asking women to fill out applications because they were opening up a new branch and were now recruiting, we had over 60 women show up at 9:00 o’clock in the morning. . . . That’s where the priority is: work. They need money.
Immigration-related issues and abuse. Immigration-related issues and abuse also emerged as significant for these health promoters. As Ana explained: Being undocumented brings a lot of depression, stress, and physical health problems for women. For example, a woman gets married to someone who she is hoping will petition for her and it ends up that he does not go to the INS office to petition for her after all. And he holds on to that situation so that he can have her under his control for as long as possible. And then for a woman who has children and needs to come [to the U.S.] sometimes she will have to also rely on her partner to petition for their children. So she will stick around in that relationship and she will suffer through it until at least her children are here and she can navigate the system on her own.
Unequal gender-based power relations. Health promoters also pointed to traditional patriarchal gender relations within the Cape Verdean culture. In Marlene’s (a 28-yearold health promoter from Cape Verde with four years of experience) words: If the woman’s male partner knows that you, as a health promoter, are the one that is trying to help his wife, he will get angry. I remember one time when we did a workshop on HIV/AIDS and gave the women some condoms and asked them to take them home. One of the women came back saying that her husband was very angry, wanting to know why the health promoter had given her condoms and accusing his wife of cheating on him and lying to him.
Cultural taboos. Health promoters also mentioned cultural barriers. As Rosie (a 33-year-old health promoter who was born in the U.S. and is in her fifth year of practice) put it:
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The biggest issue with HIV is that you have to talk about sexuality because you can’t do prevention without talking about your sex life so that you know what the risk factors are. . . . And that’s a taboo subject for Cape Verdeans and even more so for women because they’ve been taught that you don’t talk about those things. . . . Those are things men talk about at the bar. It’s okay for men to joke about it and talk about it, but not for women. It’s not appropriate. It’s disrespectful and you’d probably be seen as a prostitute or a whore if you’re caught talking about it.
Discussion The findings highlight how Cape Verdean immigrant women are constrained by social, economic, and cultural barriers. Moreover, they experience isolation and abuse due to a lack of legal documents. Similar to the perspectives and experiences of health promoters in this study, research that examined the context of sexual health behaviors and the potential for sexual risk reduction among low-income immigrant Latina women revealed that gender-based power imbalances in relationships may constrain these women’s ability to negotiate condom use with their male partners.23 The health promoters’ perspectives clearly reflect their understanding of Cape Verdean women’s health problems as having complex origins and as embedded within a multi-layered context of interpersonal, social, economic, contextual, and cultural forces. Thus, these findings can be understood within a broader, social-contextual theoretical framework.1–8,24–25 This framework is useful in embedding these women’s health problems and health behaviors as described by the health promoters in the context of the women’s realities. Moreover, the findings suggest that health promotion with this population must be deeply embedded and yet transformative of the culture and contextual inequalities as depicted by the health promoters. Although this study exemplified the potential of grounded theory as an approach to creating and analyzing knowledge critically based on the perspectives and practices of Cape Verdean women health promoters, it is limited in terms of generalizablity. Despite this limitation, examining how this group articulated and experienced health promotion with Cape Verdean immigrant women provides useful insights for understanding other health promoters’ work, particularly those who strive to promote the health of immigrant women in the U.S. Future research on health promotion with other immigrant groups that integrates a social-contextual theoretical framework may bring us closer to reducing health inequities by race/ethnicity and socioeconomic position in the U.S., thereby achieving the federal government initiative of Healthy People 2010.26
Acknowledgments The author is grateful to the individuals who agreed to be interviewed for this study, without whom it would have been impossible to conduct this research.
Notes 1.
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